Healthcare Provider Details

I. General information

NPI: 1528001419
Provider Name (Legal Business Name): MICHAEL ONOFRIO PETRELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 LAFAYETTE AVE
SUFFERN NY
10901-4812
US

IV. Provider business mailing address

255 LAFAYETTE AVE
SUFFERN NY
10901-4812
US

V. Phone/Fax

Practice location:
  • Phone: 845-368-5048
  • Fax:
Mailing address:
  • Phone: 845-368-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA07429400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number237170-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: